Saturday, June 15, 2013

After the president appointed a new prime minister, the bill was passed making women joint heads of the household.

But this has done little to change centuries of patriarchal traditions and cultures in rural areas.

"Today our law makes no distinction between men and women for the acquisition of properties," explains Maitre Kone Mahoua, the vice-president of the Association of Female Lawyers in Ivory Coast.

"But in rural areas some beliefs and customs still have an impact," she says.

Ms Mahoua describes how "women are weak because they are the ones for whom dowry is given", and that they, too, are seen as "property of the man".

It is not unusual in some African countries for the women and children to be handed over to the husband's family if he dies - the woman sometimes being "obliged" to marry another male member of the family in order to keep her children.

"We need to start sensitising our sisters in the rural areas so that they can have the same rights as men," she says.

1. Universal health insurance vouchers on exchanges, with means-tested subsidies and also a mandate. The logic of this can work just fine, but it is quite expensive as it would exist in the United States and we end up spending too much on health care. Over time it would be accompanied by say a five percent VAT.

3. The Singapore system, involving single payer for catastrophic expenses and health savings accounts for smaller expenditures. To varying degrees you can combine this with forced savings for the HSAs and price controls on service provision, both of which you will find in Singapore. Where “catastrophic” starts can vary as well. This is my first choice, although if you wish to dismiss it as “utopian” for the United States you have a point. I’ll get back to that.

4. One particular path for how ACA could evolve into a (relatively inefficient) form of a Singapore system. Imagine that the mandate becomes fairly narrow with time, while at the catastrophic end insurance companies evolve into (inefficient) public utilities. Health savings accounts are reintroduced through new legislation, perhaps under a Republican administration. Here is one discussion of that path.

5. The mandate and subsidized exchanges under Obamacare prove unworkable and eventually they are abandoned either partially or in full, or in some states but not others. Their place is taken by a Medicaid expansion. Coverage is not universal, though it is higher than pre-ACA, and of course coverage under the status quo is not going to be universal either.

Like Cowen, I believe that #3 is the best case scenario for the U.S. health care system, but I agree that it is unrealistic. Unlike Cowen, I think that #6 is more realistic than he believes. I think the ACA is deeply flawed, but I think it's likely that it will endure in the short and medium term for a few reasons:

The current administration is deeply committed to maintaining the ACA in something close to its current form. They will be willing to take a fiscal hit on Medicaid and the Marketplace subsidies in order to make it work. They will have a couple of years to tweak it in hopes of ensuring its success or at least maintaining an illusion of success.

There is a decent chance that a Democrat will win the presidency again in 2016, and while future Democrats will be less committed to the ACA than the Obama administration has been, they will be more likely to stick with the status quo. Even if a Republican wins, the current political system is so stagnant as to make legislative reform unlikely in the short to medium-term.

Once the ACA has been in place for several years, it will have its own entrenched special interests that make it difficult to reform.

For all the discussion about them, the ACA's health insurance market reforms touch a relatively small segment of the population. Several states, such as New York, have muddled along for more than a decade with health insurance markets in worse condition than the ACA is likely to be.

For many consumers, premiums will not rise too sharply. The linked article is a bit optimistic, but I agree that in the short-term rate shock will not be too drastic in 2014. The ACA's insurance market reforms may not be great long term solutions, but many--such as the minimum loss ratio (MLR) provision and the rate review provision--are likely to keep premiums from rising too steeply in the short term. Costs to consumers may rise, but they will likely do so in the form of increased co-payments.

Ultimately, I think that the ACA's Marketplaces will survive in the medium term with some possible minor changes, such as a rise in the maximum deductible and the paring down of some essential health benefits. I also think that Cowen's #7 is a realistic scenario, although it will be in the context of #3.

Syria is undergoing moral regression (one NYT update here), just as Lebanon did in the 1970s or the former Yugoslavia did in the 1990s or for that matter Germany in the 1930s. The behavior of the government is far more evil and oppressive than before, while the moral quality of the opposition is worse than what we might have expected several decades ago.

That said, most of the world is not regressing morally and arguably can be seen as advancing morally, at least on the fronts of general tolerance, democracy, and the moral virtues which are encouraged by prosperity and market exchange.

Syria is only a small percentage of the broader world and there are only a few other places which count as (possibly) morally regressing. In total they will not sum to a billion people. Just for purposes of argument, if you toss in DRC and parts of Pakistan and Egypt, along with a few other areas, let us say it runs at five percent of the world’s population which is morally regressing (though DRC has made some very recent progress and is arguably the new undervalued nation).

Does this argument imply that countries that are not morally regressing are in fact progressing, or is it possible to remain morally static? Is it even worthwhile to think of whole societies as morally regressing or progressing?

To the latter, yes, I think so. As for whether most societies are morally progressing or morally static, I think the answer is that most societies are morally progressing at a very slow rate, but that crises puncture these gains and cause a rapid crash in moral capital, which can then take generations to rebuild.

In Bill James' Popular Crime, he explains how American violence levels were abnormally high for a generation after the Civil War, which makes a lot of sense, since there were undoubtedly a lot of people with PTSD (although we didn't have a word for it at the time) going around and trying to function normally in a society without any concept rebuilding mental health. So we had decades of peace and moral growth, followed by the Civil War, in which moral capital crashed, followed by several more decades of peace in which moral capital eventually surpassed its previous level and continued upwards.

One worries about a similar fate for the Cote d'Ivoire, where decades of peace and increasing prosperity were undermined by an irresponsible political class at the turn of the century, which encouraged xenophobia and led to violence and moral regression. Rwanda provides a hopeful counterpoint to this narrative.

Monday, June 10, 2013

Private insurance in particular has very high administrative costs. U.S. insurance companies often spend 25% to 30% of total revenue on expenses other than patient care (sales, administration, and profit). In addition, doctors and hospitals also have substantially higher administrative costs in the United States than they do in other countries. Studies report that advanced American hospitals have two full-time administrative employees for each occupied bed, about ten times as many as do comparable German hospitals.

That's from Roberts and Hsiao. It's a decade old, but such statistics make me skeptical that any set of health reforms would be sufficient to make the private health insurance market function better than the hybrid fee-for-service/single-payer Singapore-style system or even a single-payer Canada-style system.

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Fulbright-Clinton Fellow in Abidjan -- Health Policy Researcher, Relativist, Incrementalist, Seeker of Knowledge -- All views are my own and do not represent the Fulbright Program or the Department of State
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